Medicaid and Healthy Michigan Plan New Member Survey

At McLaren Health Plan, we care about your privacy. The Protected Health Information (PHI) we use or disclose is private. Only people who have both the need and the legal right may see your PHI.

This survey should be completed and returned to McLaren Health Plan via mail, online by using the QR Code or visiting McLarenHealthPlan.org.

References:

The questions in this survey are adapted from various validated sources to ensure comprehensive and accurate assessment. For a detailed list of references and permissions, please visit our MHP Member Survey References Page.

Additionally, many of these questions are derived from The AHC Health-Related Social Needs Screening Tool developed by the Centers for Medicare & Medicaid Services (CMS). For more information, you can access the full screening tool document here.

Who is completing the survey? *

Myself (18+ over)

Parent or Legal Guardian

Authorized Representative

Other Representative

Please specify who is completing the survey: *

Personal Information

Emergency room visits:

Have you been a patient in the emergency room two or more times in the past six months? *

Yes

Additional Support:

Do you need help finding a doctor? *

Yes

If you have needs that make being healthy difficult, would you like someone from our team to help you with those needs? *

Yes

Living Situation

What is your living situation today? *

I have a steady place to live

I have a place to live today, but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Food

Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.

Within the past 12 months, the food you bought just did not last and you did not have money to get more. *

Often true

Sometimes true

Never true

Transportation

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? *

Yes

Do you have a regular dentist you see for checkups? *

Yes

Are you currently experiencing issues with your teeth or mouth? *